To the Candidates: What About Primary Care?

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Dr. Douglas Kamerow says all of the major presidential candidates omit a very important issue from their health care proposals. The former assistant surgeon general's search of the health care platforms of the candidates failed to find a single mention of the term "primary care."


Health care is one of the top issues voters say they're concerned about along with the economy and the Iraq war. Family physician and commentator Douglas Kamerow has examined the health care platforms of all the leading presidential candidates and finds something missing.

Dr. DOUGLAS KAMEROW (Chief Scientist, RTI International; Family Physician; Commentator): The presidential candidates agree about the nature of the problem - health care is too expensive, too many of us are uninsured, there are too many medical errors, and the quality of care is not as good as it could be.

And the candidates also agree on many of the changes that are needed to fix things - an increased emphasis on preventive medicine and chronic disease care, wider use of computerized medical records to decrease errors and improve care, and more health and health care information for patients.

But unless I'm missing something, all of the major candidates ignore a very important issue in their proposals. My search of the health care platforms of the candidates failed to find a single mention of the term primary care. Does no one realize that the current woeful state of primary care medicine in the U.S. is both a likely cause of many of our problems, as well as a potential solution for them?

Primary care doctors include family physicians, general internists, and most pediatricians. They're our first contact with health care and they provide ongoing continuity of care. The advantages of a strong primary care system had been proven in studies around the world. Where there's good primary care, patients have reduced death rates and better outcomes from heart and lung diseases. They're hospitalized less frequently and use emergency services more appropriately.

Strong primary care is associated with better delivery of preventive medicine, and more early detection of cancer. Patient satisfaction is better in primary care patients. And finally, medical care delivery by primary care clinicians costs less and uses fewer tests. And, by the way, outcomes are similar.

All of which argues that we should have a vigorous primary care system. But we don't. Primary care in the U.S. is in crisis and things are getting worse. Currently, primary care doctors comprise about 35 percent of our medical workforce compared to half or more in most industrializes countries.

The number of medical students choosing family medicine has decreased by half in the last 10 years. The proportion of internal medicine residents who plan careers in primary care instead of a specialty like cardiology also decreased by half.

So not only are there too few primary care doctors, but their numbers are dwindling. What will it take to reverse these trends? First, primary care doctors should be paid more. It's no surprise that medical students - many of whom have huge student loans to pay off - choose to become surgeons or dermatologists and get paid at least twice as much as primary care doctors.

Second, counseling and other time-intensive but low tech primary care services should be reimbursed generously, as should nontraditional services such as group visits and e-mail care.

Finally, there should be incentives for medical students to enter primary care. Loan forgiveness programs for primary care doctors would make higher-paying specialties less attractive. And ease young doctors' transition into primary care practice.

Primary care medicine is a crucial missing piece of the health care puzzle. It needs to be a part of the proposals of all the presidential candidates.

BLOCK: Douglas Kamerow is a health services researcher at RTI International and a former assistant surgeon general.

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